A Student Handbook of Obstetric & Gynecologic instruments

Dr. Garth McIntyre Dr. Andr R. Phillips

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Preface

During the undergraduate Obstetrics and Gynecology clerkship, students are expected to have a working knowledge of some of the instruments commonly used within the specialty. To this end we compiled photos of these instruments and accompanied them with short notes on their uses, features and a series of related oral exam topics. It is hoped that this book will make the task of learning these common tools easier.

Andr R. Phillips M.B.B.S. (UWI) Garth McIntyre M.B.B.S. (Hons.) (UWI) MRCOG (UK) Lecturer and
Consultant Obstetrician & Gynecologist School of Clinical Medicine & Research (U.W.I. Cave Hill) Queen Elizabeth Hospital Barbados

2005

Acknowledgements
We would like to thank the following persons for their contribution towards compilation of this Handbook. Cary Evelyn, Iniekem Ufford and Ingrid Osolo

Andr R. Phillips Garth McIntyre

2005

Clamps

Dunhilde Green Armytage Heaney Kochkers Littlewoods Uterine Artery

Dunhilde (Artery) clamp

Uses

Clamps arteries to achieve hemostasis Also used to hold ends of sutures,and gause packs

Features

Small, light weight. Pointed curved tip. Ratcheted.

Questions

Mostly on its uses. In Gynaecology its most common use is to mark gauze packs used to pack away bowel during pelvic surgery.

Green Armytage Clamps

Uses

Placed at edges of uterine incision made at Caesarean section, especially. at the angles

Features

1. Non-traumatic 2. Haemostatic

Questions

Caesarean section: Indications Preparation of the patient Complications Post-op management

Heaney clamp

Uses

One option for clamping the uterine pedicle at hysterectomy.

Features

1. Curved at tip 2. Ratcheted 3. Crushing Steps in an abdominal hysterectomy. What structure is at risk when clamping the uterine pedicle?

Questions

Kochkers

Uses

Holding tissue e.g. rectus sheath, ligaments

Features

1. Straight 2. Ratcheted 3. Crushing 4. Toothed Pfannenstiel incision Steps of abdominal hysterectomy. Anterior abdominal wall anatomy

Questions

Littlewoods clamp

Uses

To grasp cervix in: -D& C -Cervical cerclage -Cone biopsy -Vaginal hysterectomy
Tooted ends Ratcheted

Features

Questions

See tenaculum

Uterine Artery Clamp

Uses

To clamp the uterine arteries and cardinal ligaments during hysterectomy

Features

1. Curved tip 2. Non-toothed

Questions

1. What is the relation of the ureter to the uterine artery? 2. What is the blood supply to the uterus?

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Other Forceps

Allis Babcock Dartiques Dissecting Polypectomy

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Allis Forceps

Uses

To grip tissue with minimal trauma eg skin.

Features

Light weight Fine tooted edges. Non-ratcheted but locking. On any uses seen.

Questions

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Babcocks

Uses

To hold tissue which you do not want to damage e.g. Fallopian tubes.

Features

Atraumatic

Questions

When would you use this instrument?

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Dartiques

Uses

To hold structures without damaging them, e.g. the uterus.

Features

Non-traumatic Ratcheted

Questions

On its uses.

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Dissecting Forceps

Uses

To grip tissue during dissection Fine ones are used for cautery

Features

Toothed edges. Available without teeth.

Questions

On its uses.

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Polypectomy Forceps

Uses

Removal of polyps: endocervical, uterine

Features

1. Curved tip 2. Ratcheted

Questions

What are the causes of inter-menstruaul bleeding

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Retractors

Balfour Czerney Devers Doyens Kirschner Morris Cuscos Graves Sims

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Devers Retractors

Uses

Abdominal retractor during abdominal/pelvic surgery. Usually to hold bowel away during pelvic surgery.
Long, smooth curved blades. Available in 3 different sizes.

Features

Questions

On its uses.

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Name
Doyens

Use
Retracts urinary bladder during Caesarean section

Picture

Balfour

Retracts anterior abdominal wall during pelvic surgery e.g. hysterectomy

Kirschner

Retracts incision of anterior abdominal wall in four directions

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Name
Morris

Use
Retracts anterior abdominal wall, during abdominal/pelvic surgery Retracts layers of the anterior abdominal wall during its opening and closure.

Picture

Morris

Czerney

Retracts skin and subcutaneous tissue of the anterior abdominal wall to allow visualization of the rectus sheath

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Cuscos speculum

Uses

Used to visualize the cervix and lateral vaginal walls Allows access for Pap smear, cervical biopsy, endometrial aspiration, take swabs (ECS,HVS)
1. Two blades, handle 2. Various sizes: small, medium, large

Features

Questions

1. How would you pass a Cuscos speculum? 2. Questions on Cervical Cancer screening, Pap smear, etc.

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Graves speculum

Uses

Colposcopy As for Cuscos but requires a broken bed.

Features

1. Opens in two planes. 2. May be plain, ebonized or insulated

Questions

1. Who gets referral for colposcopy? 2. What are the indications for cone biopsy?

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Sims speculum

Uses

Used to visualize/retract the posterior vaginal wall in e.g diagnosis of U-V prolapse, D & C, hysteroscopy

Features

U shaped with vaginal blade and handle.

Questions

1. Who was Sims? 2.Why why this designed? 3.What is utero-vaginal prolapse? 4. What is stress incontinence?

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Other Gynaecological Instruments

Myomectomy screw Pap smear apparatus Colposcopy apparatus Endometrial aspirator Ring Pessary Sponge-holding forceps Metallic catheter Uterine sound Vulsellum clip

Hegar dilator Metal curette Suction curette Ovum forceps Spackmanns canula Tenaculum Trocar Veress needle

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Myomectomy screw

Uses

Removal of uterine fibroids (usually submucous)

Features

Handle, screw

Questions

1. What is the preop counselling of a patient for myomectomy 2. How would you reduce bleeding at myomectomy?

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Pap Smear Apparatus

Instruments

Features

Role

Picture

Ayres spatula

Wooden Two ends: 1- for nulliparous women 2 for multiparous women

To obtain exfoliating cells from the ectocervix

Cyto-broom

Cytology brush

Plastic, nylon bristles

To obtain exfoliating cells form the endocervix

Cuscos speculum

See above

See above

See above

Other apparatus include: gloves, lubricating jelly, fixative, microscope slide, pap smear form (duplicate) N.B Plastic spatulas exist.

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Colposcopy Apparatus

Name
Cryotherapy Tips

Use
Treatment of CIN I, Condylomata acuminata

Picture

Diathermy Loops 1 (LLETZ)

Treatment of CIN II, III

Diathermy Loops 2 (LLETZ)

Treatment of CIN II, III

Diathermy Balls

Treatment of CIN I ??? Achieving haemostasis at the crater in the cervix after conization.

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Endometrial Aspirator (Pipille)

Uses

Endometrial aspiration

Features

Plastic Narrow bore Low volume suction mechanism. 1. What are the causes of postmenopausal bleeding(PMB)? 2. How do you investigate a patient with PMB?

Questions

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Ring Pessary

Uses

Temporary support for uterovaginal prolapse

Features

1. Reusable 2. Cheap 3. Silicone/plastic 4. Some are flexible What is utero-vaginal prolapse?

Questions

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Sponge holding forceps

Uses

Alternative to Littlewoods tenaculum especially for soft cervix (e.g in pregnant patient) To hold small swabs for cleaning or swabbing during surgery
Ratcheted Blunt, non-traumatic tip.

Features

Questions

When would you use this instrument?

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Metallic urethral catheter

Uses

Empties the urinary bladder prior to surgery

Features

Metallic Hollow core

Questions

Why must the bladder be emptied prior to D&C/Laparoscopy?

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Uterine sound

Uses

To assess uterine size prior to dilating The cervix. Prior to IUCD insertion
A borrowed instrument from Urology. It was used to identify urinary tract calculi by the ting sound made when a stone was struck Calibtated for length Steps of a dilatation and curettage. On IUCD, such as suitable patient profile, complications of insertion.

Features

Questions

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Vulsellum clip (a type of tenaculum)

Uses

To clip anterior lip of the cervix during dilatation and curettage

Features

1. Multi-toothed 2. Applied vertically

Questions

As for single-toothed tenaculum

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Hegar Dilator

Uses

To dilate the cervix in: -D & C -Hysteroscopy -HSG -Dx of Cervical incompetence (Nonpregnant patient) - Cervical stenosis
Varies in sizes starting from 8 mm

Features Questions

Questions on D & C and on any of the above uses

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Curette (Metal)

Uses

Dilatation and Curettage e.g to obtain samples for analysis or commonly for removal of products of conception
A sharp curette: non-pregnant patient/diagnostic purposes B blunt curette: gravid uterus (less likely to perforate)/therapeutic use e.g. incomplete abortion 1. What are the Indications, steps involved and complications of Dilatation & Curettage?

Features

Questions

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Suction curette

Uses

For suction evacuation of the uterus in termination of pregnancy, incomplete miscarriage or hydatidiform moles.

Features

Plastic. May have a curved end to follow anteversion May be soft Steps in dilatation and curettage. Techniques for termination of pregnancy at different gestations.

Questions

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Ovum forceps

Uses

In D& C to remove large products of conception

Features

1. No ratchet ( less likely to traumatize uterus) 2. Curved tip to facilitate uterus 3. Applies less pressure at tip What is dilatation and curettage (D &C)?

Questions

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Spackmann Cervical Cannula

Uses

1. To maneuver the uterus at laparoscopy 2. Allows dye to be injected into uterus to assess patency
Secures the single-toothed tenaculum

Features

Questions

What is Laparoscopy?

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Single-toothed Tenaculum

Uses

Clips the anterior lip of the cervix in: 1. laparoscopy 2. Hysteroscopy 3.endometrial sampling 4.insertion of an IUCD
1. Less traumatic to cervix 2. Less painful to patient I.e. useful in outpatient setting 3.NO need for anaesthesia 4 applied horizontally 1. D& C questions 2. IUCD questions

Features

Questions

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Trocar (Hessons blunt) & Cannula

Uses

To facilitate entry of instruments during laparoscopy

Features

Sharp trocar. Blunt cannula Port for attachment of gas. Available in plastic (disposable) What is laparoscopy? Indications for laparoscopy

Questions

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Veress Needle

Uses

For instillation of gas (ususally CO2) into the abdomen during laparoscopy. Up to 3L of gas: 25mmHg to insert Trocar, 15mmHg to operate
Spring-loaded prevents perforation of abdominal viscera

Features

Questions

1. What is Laparosopy? 2. What is the safety mechanism of the Veress needle?

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Obstetric Instruments

Doppler Ultrasound Pinards Stethoscope Obstetric Wheel Vacuum extractor

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Doppler Ultrasound

Uses

Auscultation of the fetal heart rate(FHR)

Features

Handheld Battery operated Digital heart rate display 1.At what gestation would you expect to hear the FHR by Doppler? 2. What is the normal FHR? 3. How would you use this instrument during labour?

Questions

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Pinards Stethoscope

Uses

Auscultation of the fetal heart rate

Features Questions

Funnel-shaped to focus sound towards the ear 1. At what gestation would you expect ot hear the FHR by Pinards? 2. What is the normal FHR? 3. What can cause a or in FHR? 4. How would you use this for a patient in labour?

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Obstetric Wheel

Uses

To assist in calculating expected date of delivery

Features

Questions

1. What is Naegeles rule? 2. What factors influence Naegeles rule?

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Vacuum Extractor (Ventouse)

Uses
Features

Assisted vaginal delivery of a fetus

A: suction cap B: handle & tubing C: Hand pump (older systems used a vacuum bottle) 1. What are the indications for vacuum extractor? 2. What are the advantages & disadvantages of a vacuum extractor over forceps?

Questions

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Obstetric Forceps

Andersons Keillands Neville - Barnes Wrigleys

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Andersons

Uses

Mid-cavity or low forcep deliveries

Features

Traction handle Cephalic curves.

Questions

Indications for forcep delivery. Complications of forcep delivery.

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Keillands Forceps

Uses

Facilitates delivery when the fetal head is above station zero

Features

1. Mid-cavity/rotational forceps 2. Sliding lock (corrects asynclitism) 3. Pelvic curve less pronounced 4. Cephlic curve 5. Long shank/shaft What conditions should be met before application of forceps?

Questions

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Neville Barnes

Uses

Assisted vaginal delivery of a fetus

Features

1. Traction hook 2. Does not allow for rotation

Questions

Indications for forcep delivery.

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Wrigleys Forceps

Uses

Assists delivery when the fetal head is below station zero

1. Outlet forceps 2. Fixed/English lock 3. Pelvic curve more pronounced 4. Cephalic cuvre present 5, Short shank/shaft

Features

Questions

1. What are the indications for forceps delivery? 2. What are theprerequisites for frorceps application? 3. Which is safer: forceps or ventouse?

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Instruments by Common Procedures

I. Caesarean Section:
Green Armytage clamps Retractors: Morris, Czerney, Doyens Kochkers Dunhilde

II. Dilatation & Curettage:

Uterine sound Sims speculum Catherter: metallic/foleys Kidney dish Hegar dilators Curette: sharp/dull Tenaculum

Ovum forceps

III. Hysterectomy (Abdominal):

Retractors: Balfour, Kirschners Uterine artery clamp Dunhilde

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Index

A
Allis Forceps Andersons Forceps Ayres spatula

B
Babcocks forceps Balfour retractor

C
Cryotherapy Tips Curette Cuscos speculum Cyto broom Cytology grush
Czerney

D
Dartiques Deavers retractors Diathermy balls Diathermy loops Dissecting forceps Dunhilde Dissecting Forceps Doyens

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E
Endometrial aspirator

G
Graves speculum
Green Armytage clamp

H
Heaney clamp Hegar dilator Hessons trocar

K
Keillands forceps Kirschner Kochers

L
Littlewoods clamp

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M
Metallic urethral catheter Morris Myomectomy screw

N
Neville-Barnes

O
Obstetric Wheel Ovum forceps

P
Pipelle (see Endometrial Aspirator) Pinards stethoscope Polypectomy fprceps Pessary ring, shelf

R
Ring Pessary

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S
Sims speculum Spackmans cannula Sponge-holding forceps Suction curette

T
Tenaculum single-toothed

U
Uterine artery clamp Uterine sound

V
Vacuum Extractor Veress Needle Vulselum clip

W
Wrigleys forceps

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